Health Data Is Broken And We're Paying For It w/ Michael Meucci, CEO, Arcadia

American healthcare spends an estimated $110 per member per month just to administer itself, before a single service is ever delivered. Most of that cost exists because health data still cannot move freely between the systems that need it.

Michael Meucci, CEO of Arcadia, joins host John Driscoll to discuss why two decades of interoperability policy have failed to solve the data fragmentation problem facing health systems and payers, and why liberating that data and redirecting the administrative spend it currently requires could be the single biggest lever available for improving both the cost and quality of American healthcare.

🎙️⚕️ABOUT MICHAEL MEUCCI
Michael Meucci is President and CEO of Arcadia, a healthcare data and technology company, where he has built a 15+ year career spanning roles as CEO, COO, and Chief Growth Officer. He has been central to Arcadia's growth in value-based care, leading the evolution of its technology platform to enable data-driven decision-making and improved patient and financial outcomes for payers and providers. He holds board positions at healthcare AI platform N1 Health and Fenway Health, and serves as an advisor to value-based care enabler Guidehealth. Named a Rising Star by Becker's Hospital Review and a 40 Under 40 by Boston Business Journal, he is a member of the Forbes Technology Council and a frequent media commentator on digital health. He holds a BA in Economics and Entrepreneurial Leadership from Tufts University.

🎙️⚕️ABOUT CARETALK
CareTalk is a weekly podcast that provides an incisive, no B.S. view of the US healthcare industry. Join co-hosts John Driscoll (President U.S. Healthcare and EVP, Walgreens Boots Alliance) and David Williams (President, Health Business Group) as they debate the latest in US healthcare news, business and policy. 

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Transcript

SPEAKER_00 0:07

Welcome to CareTalk, America's home for incisive debate about healthcare, business, and politics. I'm John Driscoll, the chairman of the Yukon Health System, and today I look forward to welcome my old friend, the CEO of Arcadia, Michael Muci. Michael, welcome to the show. Thanks for having me, John. Great to see you. Well, maybe we'll start with a little bit of how did you before we get to Arcadia, let's learn a little bit about you. How did you get into healthcare and why?

SPEAKER_01 0:42

So I joined a consulting firm and Facet is a core, a core claims processing platform that is used by a lot of payers. It's been, it's a, it was a Trizetto product acquired by Cognizant. And it was does that make you a COBOL programmer? No, no, no. Facets, Facets used uh like a pretty modern SQL backend. Um, we were replacing an IBM DB2 mainframe core system. There were a lot of COBOL programmers making the migration from mainframe to facets. And actually, uh, we were the first facets of cloud implementation in 2008. And it was funny because it was private cloud at that time. Sun Microsystems was building the cloud. And I still remember uh getting to tour the data center, which was a blade farm. And it was like at the time the most modern way to build the cloud. Uh, you know, it's just this is pre-hyperscalers.

SPEAKER_00 1:38

That like defined you as kind of a software geek. You are grounded in in in basic software. Totally. Because facets drive still drives a lot of payer claims engines. Totally.

SPEAKER_01 1:51

And you know, it's the precursor to Qnext. And um it it, I think, kicked off this wave of customization of benefit plans in ways we could never customize them before because facets had infinite configurability, which was, you know, a blessing for the business model of TriZeto and Cognizant. They were able to like turn on the meter and keep it running. Every year you'd build a new plan, a new model, a new accumulator, and they got their, they got their consulting fees. Um, but it gave plans infinite flexibility to go out to employers and say, we can build a benefit plan that meets your exact needs. Um and it it infused a ton of complexity in the system. But at the same time, it allowed for like very advanced reporting. I I mean, I still remember the uh the the almost entire the underwriting thesis for this plan to spend it's a small plan, a small blues plan, and they were spending $250 million and $2008 on this migration. And their whole thesis was they wanted to be able to support large employers better with better analytics and reporting. And that required them to replace their core system.

SPEAKER_00 2:59

And it's I mean, to be fair, the complexity is both a benefit to those larger employers that really believe that a a a more tuned benefit design could allow them to actually keep, retained, and hopefully improve the health of their employees. But it made it, to your point, you know, cognizant being the big software player, Trizetto being the platform for a lot of the particularly the blues players, and even the not some of the non-blues players, it created a long tail of complexity that we're still trying to understand in terms of now actually making sense of benefit designs. So you you're you're you you start as a programmer, Michael, and then what happens?

SPEAKER_01 3:46

Well, I started, I actually started as a project manager. Um and then I got frustrated because you go into these meetings with programmers and developers. I was managing all the channel apps. So I IVR, website, the CRM tool for the call center, and how those connected to the core system, we ended up deciding to build a service bus because uh the the deployment plan, the deployment plan for the for the for the new claim system was a multi-phased rollout where they were starting with Medicaid and then moving into small and individual and then mid-sized groups.

SPEAKER_00 4:20

Anytime you touch the core claims engine of a pair, it's both expensive and complicated. It's just every one of them.

SPEAKER_01 4:29

Uh it was all of the above. And I think over the five-year life of this project, I think it cost it cost the organization three CIOs. Um and uh, you know, the great, the great irony of the entire project was the impetus to implement the system was all about analytical reporting to support their largest employer customers. Moving their largest employer customers was Wave 5. And at the time, their large employer customer was CVS. This was prior to the CVS Aetna merger. Um, by the time the project was done, CVS and Aetna had merged and they lost the employer customer irrespective. So it was like it not that I don't think they should have done the project, but it was um a very interesting capstone of the project that the entire reason they did this was to save this behemoth employer they supported, and it they lost it because of factors outside of their control.

SPEAKER_00 5:19

Aaron Powell We could we could geek out on just how self-destructive these some of these large software programs are that just go on forever, and are great for the consultants and the the IT outsourcers and not great for anybody else. Um but I think that the interest in analytics and reporting is uh real still most health plans struggle with because figuring out what you are getting for what you pay, where your problems are, what's manageable, what's not. What the sources of your is a is a major source of frustration and friction for large and small employers.

SPEAKER_01 5:55

Well, I think it's so interesting. So so from this implementation, I then decided to torture myself more and go into the land of EMR implementations because it was 2008, 2009, meaningful use was spinning up. And so I said, Well, I've I've implemented a claim system, I understand how that the claims of the house works. What does the other side look like? And so we started implementing uh and helping organizations do change management around implementing EMRs, Epic, e-clinical works, next gen.

SPEAKER_00 6:20

Um all of the electronic medical records that were state-of-the-art at the time. When during meaningful use, which was a massive uh bill and investment in IT infrastructure that the Obama administration thought would create transparency and then quality.

SPEAKER_01 6:37

Yeah, and I think it even started before the Obama administration. I think it started in it started with the American Recovery Act, uh, which I think was a Bush uh policy. Or I can't recall now.

SPEAKER_00 6:48

But the on-chit the- I mean, just to your your as we geek out of this, the under Secretary Levitt, there was a lot of interest in in investing in and supporting the standardization and creating of standards so that you could have sort of a uniform data set that you could then turn analytics around. And they started to get through the Office of National IT security, you know, the David Braille job that to to to sort of set up those standards. And then you were the Recovery Act was really the post-08 part of the the Obama administration saying, okay, we now that we've got a because there is a bipartisan agreement that data should be standardized, if not free, then fairly available, and and and everyone should have their own data. Trevor Burrus That that would create a rationale would give clinicians the ability to actually improve quality, because there was a very important study to Ur as human that the Academy put out that said basically medical errors are killing about 800,000. Avoidable medical errors are killing about three-quarters of a million people a year. And then that that plus the fact that they want to just put throw money at the system in post-08 after the crash of the banking system, it comes meaningful use. And then you come, you show up, Michael. What happens?

SPEAKER_01 8:12

Well, I mean, when you look at those two trends, you've got payers moving off of mainframes, employer demand to create more customized benefits, they want more data, everyone's data hungry. You've got EMRs being implemented, all of a sudden, you have more data being captured in the care setting than ever before. And then overlaying on top of that, you have CMMI in 2012 who launches the Pioneer ACO program 2011-2012. And so I think you've got these three market forces coming together. You have you have real payment reform coming from the largest payer in the world, CMS. You have payers digitizing faster and providers. And so you ask yourself, like, well, how is this different than HMO in the 90s? And it's like, finally, we have real-time data. But the dirty secret was we did it. We had it. It was being created, but nobody could figure out how to connect those data sets, the payer, the provider with payment reform. No one could do it fast. And then out of that catalyst came a lot of entrepreneurs who said, we're going to focus on this problem space. You know, Michael Weintraub and Humetica. You had, you know, through 2015, 2016, massive investment from IBM as they pulled together Watson Health, bringing Charlie's business Explorer's and uh Neil's business Fitel together with Truven and merge to create, you know, the first big healthcare AI business. And we said Which didn't work. You know, it didn't, but it defined a category. I was I was talking to someone from Watson Health the other day, and I still remember, I think it was Hems of 2015 when they made that announcement. And, you know, John, you've noticed for a long time, we've been at this since 2008. And that was a moment for us because we never had enough capital to create a category. We never had enough to go and drive the market. But all of a sudden, all of a sudden, IBM Watson did. And IBM Consulting told every health system go run an RFP, procure a population health, value-based care, data analytics AI platform. And it worked. Everyone ran these RFPs. The problem is you had vendors like ourselves who would go and get these RFPs because we've been building these systems without a category for health systems. I mean, I still remember building our earliest version of the platform with Stewart Healthcare and Beth Israel Lakey in Boston. And uh, there was a defining moment where um a health system in New England put on an RFP. It was presumed that IBM would win it. Like we knew that IBM consulting was shaping the RFP. We went and did orals, and I got a call on my birthday uh in 2015, and they said, we love Arcadia. We love what you're doing. We want to, we want to go with you.

SPEAKER_00 10:59

So step back a little bit and describe what Arcadia is and your organ how you came to it and the organization you lead, because I think that gives folks context for what you're why you're winning right now.

SPEAKER_01 11:11

Yeah, at the at the very essence of the business is we help organizations see the whole picture. We connect all of your disparate data sets, your lab, your EHR, your payer claims data, you know, your census, sometimes ERP and supply chain, and an endeavor to create a singular view of how your organization is performing. So, what does a single patient journey look like across your own assets? So if you're a health system with employed physicians and affiliates, being able to connect all those data sets and then bringing in the claims data to say what's happening outside of your employed and affiliate physicians so you can really treat the whole patient. But then also starting to look at what's the cost of goods sold on the unit of medicine? How do you start to think about what's the appropriate site of care, not just based on reimbursement, but based on your own internal costs?

SPEAKER_00 12:05

The average person, Michael, would say, well, that's gotta be easy. I mean, the hospital's got the data. We just went through, there's a national move to subsidize effectively all these hospitals and doctor groups putting in medical records. The data's there. In the rest of consumer health care, it's accessible, standardized, and available. What's different about healthcare and why do these health systems need you?

SPEAKER_01 12:31

Health systems, especially over the last decade and a half, have really focused on growing not only by acquiring practices, but by affiliating. If you look at a lot of my customers who are large academic medical centers primarily, um, and large health plans, they not only have the group of providers that they employ and they own, but they have big networks in the community, independent providers who are, you know, one to 50 docs who say, I like being independent. I like being a physician entrepreneur, I like running and owning my own practice. But I need a relationship with Intermountain or Cleveland Clinic or Vanderbilt because I need admit rights and I need to be able to be part of that network. I maybe want them to do payer contracting for me so I get better rates. Um and when they when they form these alliances, they also create massive data fragmentation. So if you take, you know, one of my customers is auctioner down in down in New Orleans, and you know, the largest health system, one of the largest health systems in the Gulf South, massive. Their network of affiliated physicians spans into Mississippi. And so, you know, yes, they have a massive Epic implementation and they have a lot of data in Epic. They probably have a dozen plus managed care contracts with national and local health plans. They get data from every one of those every month. And then they have all of these affiliations with independent providers and they need that data. They need to say, you know, if if I'm Michael Muci and I'm using a provider in Shrevefort and I get referred into one of the Oxford facilities in New Orleans for cardiac surgery, how do how do they have that totality view of what are all of my meds, my allergies, prior conditions? How do they how do they coordinate care most effectively? And then how do they share discharge instructions back to my primary care when I when I'm discharged for that episode? So we sit all that together. And and if you look at this administration and what Amy Gleason is doing and what Chris and Dan have been really focused on, one of their biggest Hallmark initiatives. All of them. One of their biggest initiatives is interoperability, which we've been talking about interop since 2009, when we start it doesn't work. It's great point to point. If you want like a single medical record for a person, you can go query that over a national network. But increasingly, what what health systems and health plants need is they need a massive amount of data. And and and even with all this effort on interoperability, I was just having this conversation with my team this morning. You can't go hit a fire server and say, I want to patient records for every single patient in your database. It would bring the system down. And so while interop works for a series of use cases very well, the labs, admin discharges, when you want to run real analytics of like what's the health of my population and what's the shape of the patients that I serve, what's the shape of the member, the member population that I'm supporting? You need big data analytics platforms and you need the connectivity to hydrate those. And so at the core of what we do is we do that. And then over time, we've added application layers to then take that data, turn it into insights, you know, who are your rising risk patients, which patients are most impactful, where you can really change the trajectory of care.

SPEAKER_00 16:01

So does do the feds need to do anything more on interoperability, or do we just need to have, you know, de more buy the more health systems and docs need to buy more systems like Arcadia?

SPEAKER_01 16:12

Uh I think we have a lot of work to do from a from a policy perspective on interoperability. A little a lot of it, and I'm I'm not a big government supporter, but we need some enforcement. There are the standards exist. And if you look at uh the Office of the National Coordinator, you know, kind of responsible for defining standards, what interoperability means, enforcement. There's been, I think, an unfortunate lack of enforcement. And I think this administration's bipartisan. I mean, I don't mean no one has enforced this stuff ever. No, because there's there's uh, as is the case with a lot of stuff in Washington, there's like massive bodies of people who lobby to say, oh, you can't enforce this. You know, there are large EHR vendors who have invested fake in making it hard to get data out of their platforms because that gives them Yeah, sure. And and Oracle and eClinical works. I mean the market leaders have a moat because they have these massive data sets. And you know, some of the most active voices in lobbying, both for and against interoperability, are oftentimes the vendor community. If you look at TEFCA, which is the kind of the the until the CMS the line networks, it was the national kind of OER.

SPEAKER_00 17:37

It's the rules of the road for interoperability. And theoretically, we'd set up guidelines that would require you know interoperability is just another way of saying getting the getting clean data back and forth. And having making everyone accessible. It's just not we complicate it with all the with all of the acronyms. But if you don't enforce it, those those the the the the uh the drawbridges are up at the castles of of of uh of the incumbents.

SPEAKER_01 18:09

I mean you you've spent a lot of time around health plans. Health plans have a right to access medical records on their members when there are encounters. The way you do that today, and for the last two decades, is you go contract with PsyOx Datavant and you say, here's a list of my members. They had encounters, I need their charts. And Kyle has a team of people who you know pound the phones, increasingly use interoperability standards, but like that business is it's a remarkable business because what they do is what we do electronically, they do pretty manually. And when you think about the the federal government and how they've mandated policy, one of the challenges I see is the the last iteration of Tefka had great use cases around treatment. I'm a physician, I want John's medical record because I'm going to perform a service for John. Tefka created like some really nice rails that work. The challenge, though, is if you're if you're Blue Cross Blue Shield in Massachusetts, and you know, John, you're you're our member, and I need to audit the way that I pay to pay to claim, and I need the medical record to do that. There was never an operational or payment use case that we could get through the administration around TEFCA because too many people lobbied against it. People are fearful that payers will use the data inappropriately, or they'll use set rates. And so both the providers and the technology vendors or uh EHR vendors made it really hard to move those use cases forward. So we have a great set of treatment rails, a great set of individual access rails. If I'm a consumer and I want my own medical records, there are increasingly a lot of ways for us to get that. And you see a ton of announcements from Anthropic and Perplexity and uh OpenAI today with partners on how do you access those networks. But fundamentally, where there is a massive amount of money spent by payers on payment integrity is just getting the data. And when you think about the admin burden of care in the country, it's just low-value spend, but it's needed.

SPEAKER_00 20:08

Trevor Burrus, Jr.: Contextually, we have a $6 trillion global budget for health care. And as much as 20 to 30 percent of it's SGNA that you could probably see go away, you're saying that that's addressable through these electronics, through just cleaning up the electronic clutter. And getting data, and regulation.

SPEAKER_01 20:30

No one's going to shoot. Now you're a government guy. No, I I preface this by saying I'm not a big government guy. However, I think we need some regulation enforcement around it. Because otherwise, there's no incentive for large provider systems to share data more with payers. There's no incentive for Epic and Oracle and eClinical works to make it easy to get the data. Like structurally, we're spending all this money that doesn't change, it doesn't change any health outcomes. It might make it so that, you know, CVS doesn't overpay for a claim. It might make it so that Vanderbilt can charge more for a specific claim, but like we're not, we spend all this money in healthcare, whether it's on prior authorization, payment integrity, Rev Cycle. Uh, we spend all this money on how we get paid. And uh we're owned by a private equity firm. And the the head of healthcare, he's he's from Stockholm. And he said, you know, my favorite fact about American healthcare is from the day we are born, there's like $110 per member per month cost of just having healthcare, not the services, the administration of healthcare. It's just like, that's a lot of money just to exist. And like that to me is the opportunity. And if we could take that and cut it down by 75% and redeploy it to investing in prevention, keeping people healthy, reducing disease progression, slowing disease progression, like we'll have a more healthy populace. We talk about things.

SPEAKER_00 21:53

What's that gonna take? I mean, that's a great idea, but what's that gonna what's what's it gonna take to clean up The regulatory games and the administrative clutter to actually get to a place where we're paying less and getting more from our healthcare system.

SPEAKER_01 22:12

I think that the first is we we need to finish the work that was started by prior administrations on just making it easier to exchange data. Frankly, businesses like mine shouldn't make the amount of money we do just moving data around. We should get paid to use the data to impact outcomes, whether it's reducing administrative cost or improving trend. And that that requires government intervention. The free market has proven that it cannot do it on its own. But from there, then there emerges this massive market. You know, when you start to think about the amount of money we spend just adjudicating payment, like if data were moving more freely, my thesis is that will collapse and we will spend less money arguing over how much we should get paid. And we can start to focus on let's pay people faster, let's move to alternative payment models faster, let's empower consumers to be part of their care. You know, we're we're coming off of health evolution last week, where, you know, my big takeaway is we have a workforce problem in the United States, and AI is well positioned to help address this. You know, AI can do things, AI can automate things that humans can do. It could if we let it. But I think a lot of people are standing in the way. I mean, I'm I'm on the board of a uh of a healthcare organization and we just were going through a union negotiation with clinicians. They don't want to be replaced by AI. My comment was we don't want to replace clinicians with AI. We want clinicians to create access and capacity and we want to enhance them. And when you think about what AI can do, it can either automate things that humans can do, but more importantly, it can do things that humans can do. It can see things we can't see. And what I'm most excited about, and where I think if we can liberate the data and start to redeploy some of this admin spend where we've we've dedicated to just moving data around, we can start to say, let's get every healthcare consumer a care manager. I've been, I've been studying um the way that the US effectively got all of its, a lot of people to understand how credit scores work. And we did it by like forcing the financial companies that create these scores to create interoperability so that individuals could access information. Anybody could access them. And for free. And then you have companies like Credit Karma that pop up and they say, download this app, and we're going to give you like daily coaching on, you know, pay off this loan or open this credit card to create more evolving credit.

SPEAKER_00 24:36

Like, so you're you're you're painting a future where all of the cutting, cutting if the rules are clear and the data is free and the data is conventionally available, we can lower costs and improve outcomes.

SPEAKER_01 24:49

I that's my my belief, yeah.

SPEAKER_00 24:52

Well, that's that's not a bad place to wrap then, Michael. Uh so uh thank you for joining us today, Michael. This has been a really interesting sort of cook's tour of the path from uh the early efforts at interoperability to a realistic view of what's going on now and how Arcadia can help providers and potentially payers figure out where there's opportunity and and also paint a little bit of a future of what could happen if we really engage consumers. So I'm John Driscoll, the chair of the UConn Health System. Thanks, Michael, for joining us today, the CEO of Arcadia, a leading edge health data information platform for payers as well as providers. And uh, if you like what you heard or you didn't, we'd love you to subscribe on your favorite service. Thanks, Michael. Thanks, John.